Hoarseness results from imperfect phonation due to impairment of normal vocal cord mobility or vibration. It is an important symptom as it may signal a serious cause such as malignancy or a disease with potential for airway obstruction.1 RAYMOND L CARROLL 1996
Hoarseness (dysphonia) is defined as an altered voice due to a laryngeal disorder.2 It is an important symptom of laryngeal disease presenting in general practice, and ranges from the very common, trivial, self-limiting condition of viral upper respiratory tract infection to a life-threatening disorder (see TABLE 46.1). It may be of sudden presentation lasting only a few days or develop gradually and persist for weeks or months. The cut-off point between acute and chronic hoarseness is three weeks’ duration, by which time most self-limiting conditions have resolved. Hoarseness pertains to harsh, raspy, gravelly or rough tones of voice rather than pitch or volume. Rarely, hoarseness can be a functional or deliberate symptom referred to as ‘hysterical aphonia’.3 In this condition, people purposely hold the cords apart while speaking.
Table 46.1Hoarseness: diagnostic strategy model ||Download (.pdf) Table 46.1 Hoarseness: diagnostic strategy model
Viral URTI: acute laryngitis
Non-specific irritative laryngitis (Reinke oedema)
Vocal abuse (shouting, screaming, etc.)
Nodules and polyps of cords
Presbyphonia in elderly: ‘tired’ voice
Serious disorders not to be missed
Cancer: larynx, lung, including recurrent laryngeal nerve palsy, oesophagus, thyroid
Imminent airway obstruction (e.g. acute epiglottitis, croup)
Other rare severe infections (e.g. TB, diphtheria)
Motor neurone disease
Aortic arch aneurysm
Pitfalls (often missed)
Benign tumours of vocal cords (e.g. polyps, ‘singer’s nodules’, papillomas)
Gastro-oesophageal reflux → pharyngolaryngitis
Vocal cord palsy
Physical trauma (e.g. post-intubation), haematoma
Fungal oropharyngeal infections (e.g. Candida with steroid inhalation, immunocompromised)
Allergy (e.g. angioedema)
Vocal cord dysfunction
‘Floppy trachea’ syndrome
Systemic autoimmune disorders (e.g. SLE, Wegener granulomatosis, myaesthenia gravis)
Seven masquerades checklist
Smoking → non-specific laryngitis
Steroids → steroid inhaler laryngitis
Is the patient trying to tell me something?
Key facts and checkpoints
In acute hoarseness, the diagnosis is usually obvious from the history alone. Examples include acute upper respiratory tract infection (URTI), vocal overuse or regular steroid inhalation.
Think ‘hypothyroidism’ if unusual hoarseness develops.
Laryngeal cancer must be excluded if hoarseness persists for longer than 3 weeks in an adult. It can arise intrinsic or extrinsic to the vocal cords.
Intermittent hoarseness is invariably secondary to a benign disorder. Constant or progressive hoarseness suggests malignancy.
Non-malignant vocal cord lesions, which include polyps, vocal nodules, contact ulcers, granulomas, other benign tumours and leukoplakia, account for about half of all chronic voice disorders.
In cases of chronic hoarseness the larynx must be visualised for diagnosis but the following are common: